An assessment communicates, in summary form, the results of the information gathering process, through history, examination and investigations, the current diagnoses of the team regarding the patient.
A good assessment is organized by relevance and provides for each diagnosis listed the degree of acuity therefore informing the sequence of the actions in the plan.
The assessment thus synthesizes pieces of information into a coherent whole. It is moving and dynamic but also grounding. The acute condition may be resolved, but some other condition for example, the patient’s uncontrolled Diabetes may still extend the hospital stay.
Here are some tips on how to write assessments:
Prioritize, but be complete.
Determine what is the most important or most acute condition and put it first. However ensure to be comprehensive with your assessment list.
An assessment isn’t static. As the patient continues in the admission more and more information will be gathered and therefore the initial assessment should be increasingly honed and perfected.
example
Mary A, 69 yo F is Diabetic and presents with a fall from standing height and pain to Left hip. Labs show anemia, low albumin; random central glucose is 20mmol/L. X ray confirms L hip fracture.
Assessment:
Left hip fracture
Uncontrolled DM
Anaemia ? Cause
Hypoalbuminaemia ? Cause
No problem left behind.
Make reasonable attempts to account for every problem that the patient has. Unaccounted for problems, often denoted shorthand as Query cause…should make you uncomfortable, like a stone in your shoe.
example continued
Mary A’s fracture pattern is reviewed, it appears pathologic. Further labs are ordered, confirming elevated calcium and markedly elevated total protein. She is given over 4L of intravenous fluid each day for 3 days and on day 4 is noted to be dyspneic.
Assessment
Likely fluid overload-iatrogenic (not dyspnea? Cause)
Pathologic L hip fracture
Uncontrolled DM
Anemia ? Cause
Hypercalcemia ? Cause
Use connectors and qualifiers.
Words such as complicated by, secondary to, presumed help to bind up the problems into a cohesive diagnosis.
example continued
Mary A’s additional workup suggests Multiple Myeloma. She receives intravenous furosemide and her dyspnea resolves.
Assessment
Presumed Multiple Myeloma complicated by L hip fracture-pathologic
Moderate Anaemia of inflammation
Moderate hypercalcemia – resolved
Iatrogenic fluid overload- resolved
Uncontrolled DM
Dont be left behind!
Progress notes are just that, really a catalogue of directional movement. ‘Stable’ is probably a better descriptor for vitals than is it for problems. Be as descriptive with adjectives used for the problems. The assessment should convey almost optically a snapshot of the patients state.
Example continued
Mary A has her hip replacement carried out and is deemed ready for discharge but has been on sliding scale insulin for her diabetic control with GMRs in the high teens to twenties.
Assessment
Presumed Multiple Myeloma complicated by Pathologic L hip fracture status post ORIF
Moderate hypercalcemia resolved
Moderate Anemia of inflammation
Moderately uncontrolled DM
Iatrogenic fluid overload- resolved
Keep practicing
Keep reading, keep assessing. This will increase the sophistication and the “economy” of your assessment, that is your assessments will be increasingly meaningful and succinct.
example continued
Mary A’s has finally got to the point of discharge! Her metabolic issues have been addressed with targeted therapy for her elevated calcium and blood sugar. Her discharge assessment
Assessment:
Presumed Multiple myeloma complicated by Pathologic Left Hip fracture status post ORIF
Moderate hypercalcemia now resolved
Moderate anemia
Diabetes Mellitus controlled
Iatrogenic fluid overload- resolved
Dr. Ryan Brooks
Thank you Dr. Brooks for contributing this article for medical students, new doctors and even more experienced doctors! If you would like to contribute an article to The Layman’s Doctor send an email to thelaymansdoctor@gmail.com.


Dr. Ryan Brooks is an Internist who completed his Internal Medicine Residency Programme at the University of the West Indies. He is now pursing his fellowship in Hospital Medicine abroad.
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